RSAC REGION III - DATA ENTRY As of Decemeber 14 2018.xlsm

PALARONG PAM
Data Entry (Athlete)
Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
ronie/17
with appreciation and thanks to ronie almia, cotabato city division, region 12
LARONG PAMBANSA
pletion
nks to ronie almia, cotabato city division, region 12

NSA 2019
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
A B C D E F G H I J K L
1 REGION III - CENTRAL LUZON
2 DIVISION BULACAN
3 SCHOOL YEAR: 2018 - 2019 Year of Palaro 2019 back to main
4
5 NAME: Dela Vega Myla C
6 (Last) (First) (M.I.)
7 CONTACT NUMBER: Chaperon /Asst. Coach New Entry
8 SEX: Coach-CLRAA
9 LEARNER REFERENCE NUMBER (LRN) Coach Palaro Date
10 DATE OF BIRTH: (mm/dd/yyyy) Encoder 10/13/2018
11 AGE Date Encode 118 years 9 months 15 days
12 PLACE OF BIRTH: Dsac Control Number
13 SCHOOL NAME: SCHOOL TYPE:
14 SCHOOL CODE Coach CLRAA/Palaro : Designation
15 ADDRESS OF SCHOOL: Coach CLRAA/Palaro : School
16 HOME ADDRESS:
17 PARENTS:
18 Fathers Name Mother/Guardian
19 ADDRES OF PARENTS: SDSuperintendent
20 GRADE LEVEL: Administratice Of
21 SECTION:
22 EVENT:
23 COACH: Date Accomplished Remarks 1
24 TEACHER / ADVISER : UNIT/ZONAL MEET 2
25 SCHOOL HEAD/ REGISTRAR: PROVINCIAL/CITY MEET: 3
26 GUARDIAN: CLRAA MEET : 4
27 DIVISION SPORTS OFFICER: PALARONG PAMBANSA:
M
1
2
3
4
5
6
7
8
9
10
onths 1511days
12
13
14
15
16
17
18
19
20
21
22
23
24
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26
27
AR-I (ATHLETE RECORD)
III - CENTRAL LUZON
Region
BULACAN
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: Dela Vega Myla C

(Last) (First) (M.I.)
Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 Type of School: 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/1899 0 UNIT MEET/ZONAL MEET 2018 0
12/30/1899 0 PROVINCIAL MEET/CITY MEET 2018 0
12/30/1899 0 REGIONAL MEET/CLRAA MEET 2019 0
12/30/1899 0 PALARONG PAMBANSA 2019 0
(Use separate sheet if necessary)
Myla C Dela Vega

Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
UNIT MEET/ZONAL MEET 2018 12/30/1899
PROVINCIAL / CITY MEET 2018 12/30/1899
REGIONAL / CLRAA MEET 2019 0 0
PALARONG PAMBANSA 2019 0
EPS I / SGOD
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: 12/30/1899 Date: 12/30/1899
DSAC Control Number 0 0 12/30/1899

AR-01 Encoded by : Date
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
III - CENTRAL LUZON
(Region)
BULACAN
(Division)
(Name of School)
0
(School Address)
CERTIFICATE OF ENROLMENT
Date: 12/30/1899
To Whom It May Concern:
This is to certify that Myla C Dela Vega has been
enrolled in the Grade 0 Section 0 for the School Year 2018 - 2019
0
Teacher / Adviser
(Signature over printed name)
Certified True and Correct :
0
Principal/School Head/Registrar

C E F - 06 Encoded by : Date

III - CENTRAL LUZON
(Region)
BULACAN
(Division)
0
(Name of School)
0
(School Address)
CERTIFICATE OF COMPLETION
Date: 12/30/1899
This is to certify that Myla C Dela Vega has completed

the Grade 0 (Elementary/Secondary Level) for the School Year 2018 - 2019
0
Teacher / Adviser
Certified True and Correct :

0
Principal/School Head/Registrar
DSAC Control Number 0 0 0

C O C F - 07 Encoded by : Date
DEPARTMENT OF EDUCATION
III - CENTRAL LUZON
Region
BULACAN
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name: Myla C Dela Vega
Age: 12/30/1899 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0 0 0
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETH
DECIDOUS TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
X - TOOTH INDICATED DU -DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL -MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU -FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn -NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm -MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST

DHR F - 02 Encoded by : Date
III - CENTRAL LUZON
(Region)
BULACAN
(Division)
0
(Name of School)
0
(School Address)
P A R E N TA L C O N S E N T
Date: 12/30/1899
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter Myla C Dela Vega in the
District Meet,City/Division Meet,Regional Meet and 2019 Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Signature of Father Signature of Mother

0 0
Name of Father Name of Mother
0 Remarks:
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
0 0
Teacher-Adviser School Head/Registrar
Signature Over Printed Name Signature Over Printed Name

P C F - 08 Encoded by Date
III - CENTRAL LUZON
(Region)
BULACAN 0
(Division)
0
(Name of School)
0
(School Address)
MEDICAL CERTIFICATE
( Athlete )
Date: 12/30/1899
This isThis is to certify that I have personally examined Myla C Dela Vega
(Name)
age 0 sex 0 born on 12/30/1899 and have found that he/she is

physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.
Event: 0
Physical Examination
Date examined: _ 12/30/1899

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medical Officer
License No.
PTR.:
Date: 12/30/1899

M C F - 09 Encoded by Date

III - CENTRAL LUZON
(Region)
BULACAN
(Division)
0
(Name of School)
0
(School Address)
MEDICAL CERTIFICATE ABNORMALITIES

( BASED ON VISUAL, PHYSICAL
ASSESMENT AND INTERVIEW )
Date of Examination: ______________________________
Medical Examination following post
If Athlete had a Concussion in the
period after Concusion was normal Normal Abnormal
past year please cetify that:
Athlete Fit to Box
List abnormalities not covered in

General Medical Exam
specific system exams below:
Mental Status/ Psychological Briet survey Normal Abnormal
Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)
Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib tenderness on
Chest Normal Abnormal
compession
Pulse/ blood pressure (record) Normal Abnormal
Cardio Vascular System Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm
Upper limb: shoulder wrist, hand,

Ortopedic System Normal Abnormal
fingers
Lower limb: (ankle, knee, hip Normal Abnormal
Relaxes Normal Abnormal
Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
Name of Athlete Myla C Dela Vega Event : 0

FIT UNFIT
PHYSICIAN
Signature Over Printed Name
License Number:
Date :
D S A C Control Number 0 0 0
M C F - 010 - A Encoded by Date

III - CENTRAL LUZON
(Region)
BULACAN
(Division)
0
(Name of School)
0
(School Address)
MEDICAL CERTIFICATE
( Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling, Wushu )
QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES
2. Have you ever been unconscious or had a concussion? YES NO YES
3. Have you been hit hard in the head in the last 6 weeks? YES NO YES
4. Have you had any headache in the last 2 week? YES NO YES
5. Do you have any problem in bleeding? YES NO YES
6. Does any disease run in your family ? Sudden unexfect YES NO YES
7. Have you had any surgery? YES NO YES
8. Have you ever had to stay in a hospital? YES NO YES
9. Do you have any medical dondition? YES NO YES
Myla C Dela Vega 0

Athlete Parent / Guardian
Signature Over Printed Name Signature Over Printed Name
Date Signed : 12/30/1899 Date Signed : 12/30/1899
License No.
PTR.:
Date: 12/30/1899

M C F - 010 - B Encoded by: Date

c of the Philippines
ent of Education
NTRAL LUZON
(Region)
ULACAN
(Division)
0
me of School)
0
hool Address)
CERTIFICATE
ak Silat, Taekwondo, Wrestling, Wushu )
MEDICAL
OFFICER
NO
NO
NO
NO
NO
NO
NO
NO
NO
0
Parent / Guardian
12/30/1899
0
Date
III - CENTRAL LUZON
(Region)
BULACAN
(Division)
0
(Name of School)
0
(School Address)
ATHLETES DATA PRIVACY NOTICE AND CONSENT FORM

Date: 12/30/1899
The Department of Education engages in the collection of personal information such as

the Full Name, Address, Age, Medical Records, Photographs, Videos, and Contact Information of
the Students / Athletes.
All personal information collected by the Department of Education shall be utilized for
Accounting, Auditing, Screening, Qualifying, Monitoring and other Legitimate purpose for the
conduct of Athletes Meet, Sports Competitions, Practices, and the Publication of results of Sports
Activities and Competitions.
For concerns regarding Data Collection, Access, Disclosure, Corrections, and other
issues, inquiries may be made to the compliance officer for privacy.
0
Name of School Head Email Address Contact Number
In consideration in the foregoing, I hereby authorized the Department of Education to

collect , use and process the above - specified personal information for screening qualification,
participation in athletic activities, athlete practices and training, Publication of results in athletic
activities and . In the course of my application to participate in School, Division, Regional, National
and International activities and competitions . Do hereby authorize the Department of Education
to Transmit relevant personal information to authorize the Department personnel to process
such application.
I am hereby authorizing the Department of Education to collect, process,retain, and

dispose of my personal information in accordance with the Department Policies.
Myla C Dela Vega

Student / Athlete
Date Signed :
Signature of Father Signature of Mother

0 0
Name of Father Name of Mother
Date Signed : Date Signed :
0
Coach
Signature Over Printed Nmae
Date Signed :

A D P N-CF - 013 Encoded by Date
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or
d
III - CENTRAL LUZON
(Region)
GALLERY OF ATHLETES
EVENT : 0 Division BULACAN
Certificate of Employment / Contract of Service
Affidavit / Sworn Statement
Personal Data Sheet
Medical Certificate
Coach Asst.Coach / Chaperon
Certificate of Training
Certificate of Sports Membership
Certificate of Sports Accreditation
Certificate of Commitment (Chaperon)
0 Name 0
Name of School
Address of School
0 AR - 1
P S A / NSO
Photocopy of P S A / N S O
Form 137 / SF - 10
Certificate of Enrolment
Athlete Athlete
Parental Consent
Medical Certificate
Dental Certificate
Interview
Name of Athlete
Learners Reference Number
Date of Birth
Name of School
Address of School
AR - 1
P S A / NSO
Form 137 / SF - 10
Athlete Athlete
Parental Consent
Medical Certificate
Dental Certificate
Interview
Name of Athlete
Date of Birth
Name of School
Address of School
AR - 1
P S A / NSO
Form 137 / SF - 10
Athlete Athlete
Parental Consent
Medical Certificate
Dental Certificate
Interview
Name of Athlete
Date of Birth
Name of School
Address of School
G O A - 03 Encoded by : Date
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.
III - CENTRAL LUZON
(Region)
BULACAN 0
(Division)
0
(Name of School)
0
(School Address)
CERTIFICATE OF EMPLOYMENT
(for PUBLIC SCHOOL / DEPED PERSONNEL)
Date: 12/30/1899
This is to certify that Mr. Ms. 0 is presently
employed in 0 as 12/30/1899
( Name of School ) (Designation)
or for a period of .
(Date of Appointment) (Years in the Service)
This certification is issued upon the request of 0
to coach in the Lower Meet up to 2019 Palarong Pambansa at

(Venue)
0
School Head / Registrar
Signature over Printed Name

C E F - 016 Encoded by Date
back to main
(PUBLIC SCHOOL)
III - CENTRAL LUZON
(Region)
BULACAN 0
(Division)
0
(Name of School)
0
(School Address)
SWORN STATEMENT
(PUBLIC SCHOOL)
Date: 12/30/1899
REPUBLIC OF THE PHILIPPINES
PROVINCE OF : BULACAN
CITY OF :
I, 0 , of legal age, single / married, with postal address

Name
at , after having duly sworn in accordance with the
Address
Law hereby depose and state;
Department of
That I am presently employed in the as 0
Education (Designation)
That I have been in 0 since
(Name of School) (Date of Employment)
or for a period of
(Years in the Service)
That I was designated as coach of 0 TEAM who will participate
(Event)
in the Lower Meet up to 2019 Palarong Pambansa.
That all the athlete of BULACAN who will participate in the

CLRAA and in Palarong Pambansa Meet are eligible;
That I execute this affidavit to attest to the authenticity and veracity of all the documents
Submitted.
IN WITNESS WHEREOF ; I have hereunto set my hand this day of

in , Philippines.
Affiant
SUBSCRIBED AND SWORN TO before me this __________day of 20____in

affiant exhibiting to me his/her Community Tax Certificate no.
issued on in .
0 0
Schools Division Superintendent Division Administrative Officer

S S F - 05 Encoded by Date
back to main
III - CENTRAL LUZON
(Region)
BULACAN 0
(Division)
0
(Name of School)
0
(School Address)
AFFIDAVIT
(PRIVATE SCHOOL)
Date: 12/30/1899
REPUBLIC OF THE PHILIPPINES
PROVINCE OF : BULACAN
CITY OF :
I, 0 , of legal age, single / married, with postal address

Name
at , after having duly sworn in accordance with the
Address
Law hereby depose and state;
Department of
That I am presently employed in the as 0
Education (Designation)
That I have been in 0 since
(Name of School) (Date of Employment)
or for a period of
(Years in the Service)
That I was designated as coach of 0 TEAM who will participate
(Event)
in the Lower Meet up to 2019 Palarong Pambansa.
That all the athletes record submitted are true and correct to the best of my personal knowledge
That all the athletes are not a member of the National Team, National Training Pool and Develop-
ment Pool receiving monthly stipend/allowance from the Philippine Sports Commission ( P S C )
That all the athlete of BULACAN who will participate in the

CLRAA and in Palarong Pambansa Meet are eligible;
That I execute this affidavit to attest to the authenticity and veracity of all the documents
Submitted.
IN WITNESS WHEREOF ; I have hereunto set my hand this day of

in , Philippines.
Affiant
SUBSCRIBEDAND SWORN TO before me this __________day of 20____in

affiant exhibiting to me his/her Community Tax Certificate no.
issued on in .
0 0
Schools Division Superintendent Division Administrative Officer

A F F - F - 04 Encoded by Date
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III - CENTRAL LUZON
(Region)
BULACAN
(Division)
0
(Name of School)
0
(School Address)
CONFIDENTIALITY UNDERTAKING
Date: 12/30/1899
i 0 0 of DepEd.,
Coach Designation Agency
0 hereby understand that highly confidential information is
Name of School / Office
being collected and processed from the conduct of the athletic activities and competitions with
in the Department of Education. I hereby affirm that I am authorized and designated to handle the
said information in confidential.
in this regard, any information gathered and processed will be kept confidential and will
will not be Disclosed, It may not be reproduced in whole or in part, nor may any of the information
contained therein be disclosed wwithout the prior notification or consent of the data subject
concerned nor of the Department of Education.
Furthermore, I acknowledge that the illegal and or unauthorized disclosure or use of

information collected and processed shall be subject to Administrative and Criminal liability under
the Law.
0
Coach
Date Signed :

C U F - 014 Encoded by Date

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III - CENTRAL LUZON
(Region)
BULACAN 0
(Division)
0
(Name of School)
0
(School Address)
SECURITY CLEARANCE
Date: 12/30/1899
I hereby certify that the personnel indicated below is authorized to collect, process,
retain, and dispose of personal information of Myla C Dela Vega
in accordance with the Data Privacy processes and Policies of the Department of Education.
Period of Validity
Types of Documents or of Security
Name of Coach Designation Remarks
Personal Information Clearance
0 0 1 Year
1 Year
PSA / NSO, F-137A (Permanent
Record), AR-1, Enrolment, 1 Year
Completion, Parental Consent,
Medical Record, Dental Record,
1 Year
1 Year
1 Year
All records are highly confidential pursuant to the provision of BP 232 and other relevant
Laws, rules, and regulations. Only the designated personnel may handle this personal Information
within the period of validity of their Security Clearance.
Conforme : 0
Coach
Date Signed :
0
School Head
Date Signed :

S C F - 015 Encoded by Date

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III - CENTRAL LUZON
(Region)
BULACAN 0
(Division)
0
(Name of School)
0
(School Address)
MEDICAL CERTIFICATE
( Coach, Assistant Coach, Chaperon , Official )
Date: 12/30/1899
This isThis is to certify that I have personally examined 0

(Name)
age sex and currently employed as 0

Position Designation
at 0 and have found that he/ she is Physically Fit during

School / Station
the tme of Examination, to join and to Coach / Chaperon / Officiate in the Lower Meet and up to
2019 PALARONG PAMBANSA.
Event: 0
Physical Examination
Date examined: _ 12/30/1899

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
License No.
PTR.:
Date: 12/30/1899

M C F - CO/CH/OFF - 011 Encoded by Date
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III - CENTRAL LUZON
(Region)
BULACAN 0
(Division)
0
(Name of School)
0
(School Address)
COMMITMENT FORM
( Chaperon )
Date: 12/30/1899
I, 0 , of legal age, sinle/married with a postal address

at
That I am presently employed in 12/30/1899 since

Name of School
.
Date of Employment
That I was designated as a Chaperon of 0 (Event) who will

participate in the up to 2019
( Meet )
PALARONG PAMBANSA.Do hereby commit myself to foster the Welfare of Athletes under my Care
and take the Responsibility of Watching their Wellbeing up to the duration of the MEET.
That I will not intefere in the Coaching of our Team or Act as Coach of the Athlete as it is
not my responsibility to do so.
0
Date Signed :
Attested :
0
Date Signed :

C F CH - 012 Encoded by Date

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DSAC CONTROL NUMBER Year Level Event Gender Athletes Coach Asst.Coach Chaperon Total category Total
E L E M E N T A R Y
001 003 2019 ELEMENTARY ARNIS M 3 1 4 B
9
004 006 2019 ELEMENTARY ARNIS F 3 1 1 5 G
007 016 2019 ELEMENTARY ATHLETICS M 12 2 14 B
29
017 026 2019 ELEMENTARY ATHLETICS F 12 2 1 15 G
027 030 2019 ELEMENTARY BADMINTON M 4 1 1 6 B
13
031 034 2019 ELEMENTARY BADMINTON F 4 1 1 1 7 G
035 045 2019 ELEMENTARY BASEBALL M 12 1 1 14 B 14
046 057 2019 ELEMENTARY BASKETBALL M 12 1 13 B 13
058 059 2019 ELEMENTARY CHESS M 2 1 3 B
7
060 061 2019 ELEMENTARY CHESS F 2 1 1 4 G
062 079 2019 ELEMENTARY FOOTBALL M 18 1 19 B 19
080 082 2019 ELEMENTARY GYMNASTICS (MAG) M 3 1 4 B
083 085 2019 ELEMENTARY GYMNASTICS (RG) F 3 1 1 5 G 13
086 088 2019 ELEMENTARY GYMNASTICS (WAG) F 3 1 4 G
089 092 2019 ELEMENTARY SEPAK TAKRAW M 4 1 5 B 5
093 104 2019 ELEMENTARY SOFTBALL F 12 1 1 1 15 G 15
105 114 2019 ELEMENTARY SWIMMING M 10 1 11 B
23
115 124 2019 ELEMENTARY SWIMMING F 10 1 1 12 G
125 128 2019 ELEMENTARY TABLE TENNIS M 4 1 5 B
11
129 132 2019 ELEMENTARY TABLE TENNIS F 4 1 1 6 G
133 138 2019 ELEMENTARY TAEKWONDO M 6 1 7 B
15
139 144 2019 ELEMENTARY TAEKWONDO F 6 1 1 8 G
145 148 2019 ELEMENTARY TENNIS M 4 1 5 B
11
149 152 2019 ELEMENTARY TENNIS F 4 1 1 6 G
153 164 2019 ELEMENTARY VOLLEYBALL M 12 1 1 14 B
29
165 176 2019 ELEMENTARY VOLLEYBALL F 12 1 1 1 15 G
S E C O N D A R Y
001 004 2019 SECONDARY ARCHERY M 4 1 5 B
11
005 008 2019 SECONDARY ARCHERY F 4 1 1 6 G
009 013 2019 SECONDARY ARNIS M 5 1 6 B
13
014 018 2019 SECONDARY ARNIS F 5 1 1 7 G
019 028 2019 SECONDARY ATHLETICS M 15 2 17 B
35
029 038 2019 SECONDARY ATHLETICS F 15 2 1 18 G
039 042 2019 SECONDARY BADMINTON M 4 1 1 6 B
13
043 046 2019 SECONDARY BADMINTON F 4 1 1 1 7 G
047 058 2019 SECONDARY BASEBALL M 12 1 1 14 B 14
059 070 2019 SECONDARY BASKETBALL M 12 1 13 B
27
071 082 2019 SECONDARY BASKETBALL F 12 1 1 14 G
2019 SECONDARY BASKETBALL 3X3 M 4 1 5 B
11
2019 SECONDARY BASKETBALL 3X3 F 4 1 1 6 B
083 084 2019 SECONDARY BILLIARDS M 2 1 3 B
7
085 086 2019 SECONDARY BILLIARDS F 2 1 1 4 G
087 096 2019 SECONDARY BOXING M 10 1 1 12 B 12
097 098 2019 SECONDARY CHESS M 2 1 3 B
7
099 100 2019 SECONDARY CHESS F 2 1 1 4 G
101 118 2019 SECONDARY FOOTBALL F 18 1 19 G 19
119 130 2019 SECONDARY FUTSAL F 12 1 1 14 G 14
131 133 2019 SECONDARY GYMNASTICS (MAG) M 3 1 4 B
134 136 2019 SECONDARY GYMNASTICS (RG) F 3 1 1 5 G 13
137 139 2019 SECONDARY GYMNASTICS (WAG) F 3 1 4 G
140 151 2019 SECONDARY SEPAK TAKRAW M 12 1 13 B
20
152 155 2019 SECONDARY SEPAK TAKRAW F 5 1 1 7 G
156 167 2019 SECONDARY SOFTBALL F 12 1 1 1 15 G 15
168 177 2019 SECONDARY SWIMMING M 10 1 11 B
23
178 187 2019 SECONDARY SWIMMING F 10 1 1 12 G
188 191 2019 SECONDARY TABLE TENNIS M 4 1 5 B
11
192 195 2019 SECONDARY TABLE TENNIS F 4 1 1 6 G
196 205 2019 SECONDARY TAEKWONDO M 10 1 11 B
23
209 215 2019 SECONDARY TAEKWONDO F 10 1 1 12 G
216 219 2019 SECONDARY TENNIS M 4 1 5 B
11
220 223 2019 SECONDARY TENNIS F 4 1 1 6 G
224 235 2019 SECONDARY VOLLEYBALL M 12 1 1 14 B
29
236 247 2019 SECONDARY VOLLEYBALL F 12 1 1 1 15 G
248 255 2019 SECONDARY WRESTLING M 8 1 9 B
19
256 263 2019 SECONDARY WRESTLING F 8 1 1 10 G
264 269 2019 SECONDARY WUSHU M 6 1 7 B
13
270 273 2019 SECONDARY WUSHU F 4 1 1 6 G
D E M O S P O R T S
2019 DEMO SPORTS AEROBIC GYMNASTICS - M/F 4 1 5 B/G
10
2019 DEMO SPORTS AEROBIC GYMNASTICS - M/F 4 1 5 B/G
2019 DEMO SPORTS DANCESPORTS - ELEMENT M 1 1 B
2019 DEMO SPORTS DANCESPORTS - ELEMENT F 1 1 G
4
2019 DEMO SPORTS DANCESPORTS - ELEMEN M 1 1 B
2019 DEMO SPORTS DANCESPORTS - ELEMEN F 1 1 G
001 2019 DEMO SPORTS DANCESPORTS - SECONDA M 1 1 2 B
002 2019 DEMO SPORTS DANCESPORTS - SECONDA F 1 1 2 G
6
003 2019 DEMO SPORTS DANCESPORTS - SECOND M 1 1 B
004 2019 DEMO SPORTS DANCESPORTS - SECOND F 1 1 G
2019 DEMO SPORTS PENCAK SILAT - SECONDARY M 5 1 6 B
12
2019 DEMO SPORTS PENCAK SILAT - SECONDARY F 5 1 6 G
P A R A G A M E S
001 004 2019 PARAGAMES ATHLETICS V.I. M 3 3 6 B
005 006 2019 PARAGAMES ATHLETICS V.I. F 3 3 G
007 015 2019 PARAGAMES ATHLETICS I.D. M 10 2 12 B
016 023 2019 PARAGAMES ATHLETICS I.D. F 10 2 12 G
024 2019 PARAGAMES ATHLETICS/SWIMMING O.H M 2 2 4 B
2019 PARAGAMES ATHLETICS/SWIMMING O.H F 2 2 G
55
2019 PARAGAMES SMIMMING I.D. M 2 2 4 B
2019 PARAGAMES SMIMMING I.D. F 2 2 G
025 026 2019 PARAGAMES BOCCE I.D. M 2 1 3 B
027 028 2019 PARAGAMES BOCCE I.D. F 2 2 G
2019 PARAGAMES M 2 1 3 B
2019 PARAGAMES GOALBALL V.I. F 2 2 G
541 87 14 31 673 673
Educational Support and Services Division
SCHOOLS SPORTS DIVISION
MONITORING AND EVALUATION TOOL

2019 CENTRAL LUZON REGIONAL ATHLETIC ASSOCIATION MEET
Iba, Zambales (February 3 - 8, 2019)
Division of : DATE :
ELEMENTARY LEVEL
ATHLETES COACH ASST. COACH CHAPERON
BOYS GIRLS MALE FEMALE MALE FEMALE FEMALE
EVENT Athletes Coach Asst Coach Chaperons TOTAL PUBLIC PRIVATE PUBLIC PRIVATE PUBLIC PRIVATE PUBLIC PRIVATE PUBLIC PRIVATE PUBLIC PRIVATE PUBLIC PRIVATE
Arnis EB 3 1 4
Arnis EG 3 1 1 5
Athletics EB 12 2 14
Athletics EG 12 2 1 15
Badminton EB 4 1 1 6
Badminton EG 4 1 1 1 7 x x x x x x x x x x x x x x
Baseball EB 12 1 1 14
Basketball EB 12 1 13
Chess EB 2 1 3
Chess EG 2 1 1 4
Football EB 18 1 19
MAG 3 1 4
RG 3 1 4
WAG 3 1 1 5
Sepak Takraw Jr 4 1 5
Softball EB 12 1 1 1 15
Swimming EB 10 1 11
Swimming EG 10 1 1 12
Table Tennis EB 4 1 5
Table Tennis EG 4 1 1 6
Taekwondo EB 6 1 7
Taekwondo EG 6 1 1 8
Tennis EB 4 1 5
Tennis EG 4 1 1 6
Volleyball EB 12 1 1 14
Volleyball EG 12 1 1 1 15
Total 181 28 6 11 226
GRAND TOTAL
Prepared by :
DSAC Chairman (Signature over printed name)
SECONDARY LEVEL - Page 1

Archery SB 4 1 5
Archery SG 4 1 1 6
Arnis SB 5 1 6
Arnis SG 5 1 1 7
Athletics SB 15 2 17
Athletics SG 15 2 1 18
Badminton SB 4 1 1 6
Badminton SG 4 1 1 1 7
Baseball SB 12 1 1 14
Basketball SB 12 1 13
Basketball SG 12 1 1 14
3x3 SB 4 1 5
3x3 SG 4 1 1 6
Billiard SB 2 1 3
Billiard SG 2 1 1 4
Boxing SB 10 1 1 12
Chess SB 2 1 3
Chess SG 2 1 1 4
Football SB 18 1 19
Futsal SG 12 1 1 14
MAG SB 3 1 4
RG SG 3 1 4
WAG SG 3 1 1 5
Sepak Takraw SB 12 1 13
Sepak Takraw SG 5 1 1 7
Softball SG 12 1 1 1 15
Swimming SB 10 1 11
Swimming SG 10 1 1 12
Table Tennis SB 4 1 5
Table Tennis SG 4 1 1 6
Taekwondo SB 10 1 11


SECONDARY LEVEL - Page 2

Taekwondo SG 10 1 1 12
Tennis SB 4 1 5
Tennis SG 4 1 1 6
Volleyball SB 12 1 1 14
Volleyball SG 12 1 1 1 15
Wrestling SB 8 1 9
Wrestling SG 8 1 1 10
Wushu SB 6 1 7
Wushu SG 4 1 1 6
Total 292 42 7 19 360
GRAND TOTAL
Prepared by :


DEMO SPORTS BOYS GIRLS MALE FEMALE MALE FEMALE FEMALE
ELEMENTARY
Aero-Gymnastics (B/G) 4 1 5
Dancesports EB 2 2
Dancesports EG 2 2
8 1 9
SECONDARY
Aero-Gymnastics SB 4 1 5
Dancesports SB 2 1 3
Dancesports SG 2 1 3
Pencak Silat SB 5 1 6
Pencak Silat SG 5 1 6
TOTAL 18 3 2 23
GRAND TOTAL
PARA GAMES ATHLETES COACH ASST. COACH CHAPERON
Athletics VI Boys 3
3 9
Athletics VI Girls 3
Athletics ID Boys 10 2 12
Athletics ID Girls 10 2 12
Athletics/Swimming OH Boys 2 1 3
Athletics/Swimming OH Girls 2 1 3
Swimming ID Boys 2 1 3
Swimming ID Girls 2 1 3
Bocce ID Boys 2
1 5
Bocce ID Girls 2
Goalball VI Boys 2
1 5
Goalball VI Girls 2
Total 42 13 55
GRAND TOTAL
Prepared by :


DATE :
Division of :
S U M M A R Y OF D E L E G A T I O N

ELEMENTARY 181 28 6 11 226
SECONDARY 292 42 7 19 360
DEMO SPORTS 26 4 0 2 32
PALA - GAMES 42 13 0 0 55
GRAND TOTAL 541 87 13 32 673
SUMMARY DELEGATION OF ATHLETES, COACHES, ASSISTANT COACHES AND
CHALERONS
Prepared by :

YEAR level event gender Athletes coach
2018 ELEMENTARY ARNIS M 3 1
2018 ELEMENTARY ARNIS F 3 1
2018 ELEMENTARY ATHLETICS M 12 2
2018 ELEMENTARY ATHLETICS F 12 2
2018 ELEMENTARY BADMINTON M 4 1
2018 ELEMENTARY BADMINTON F 4 1
2018 ELEMENTARY BASEBALL M 12 1
2018 ELEMENTARY BASKETBALL M 12 1
2018 ELEMENTARY CHESS M 2 1
2018 ELEMENTARY CHESS F 2 1
2018 ELEMENTARY FOOTBALL M 18 1
2018 ELEMENTARY GYMNASTICS (MAG) M 3 1
2018 ELEMENTARY GYMNASTICS (RG) F 3 1
2018 ELEMENTARY GYMNASTICS (WAG) F 3 1
2018 ELEMENTARY SEPAK TAKRAW M 4 1
2018 ELEMENTARY SOFTBALL F 12 1
2018 ELEMENTARY SWIMMING M 10 1
2018 ELEMENTARY SWIMMING F 10 1
2018 ELEMENTARY TABLE TENNIS M 4 1
2018 ELEMENTARY TABLE TENNIS F 4 1
2018 ELEMENTARY TAEKWONDO M 6 1
2018 ELEMENTARY TAEKWONDO F 6 1
2018 ELEMENTARY TENNIS M 4 1
2018 ELEMENTARY TENNIS F 4 1
2018 ELEMENTARY VOLLEYBALL M 12 1
2018 ELEMENTARY VOLLEYBALL F 12 1
2018 SECONDARY ARCHERY M 4 1
2018 SECONDARY ARCHERY F 4 1
2018 SECONDARY ARNIS M 5 1
2018 SECONDARY ARNIS F 5 1
2018 SECONDARY ATHLETICS M 15 2
2018 SECONDARY ATHLETICS F 15 2
2018 SECONDARY BADMINTON M 4 1
2018 SECONDARY BADMINTON F 4 1
2018 SECONDARY BASEBALL M 12 1
2018 SECONDARY BASKETBALL M 12 1
2018 SECONDARY BASKETBALL F 12 1
2018 SECONDARY BASKETBALL 3X3 M 4 1
2018 SECONDARY BASKETBALL 3X3 F 4 1
2018 SECONDARY BILLIARDS M 2 1
2018 SECONDARY BILLIARDS F 2 1
2018 SECONDARY BOXING M 10 1
2018 SECONDARY CHESS M 2 1
2018 SECONDARY CHESS F 2 1
2018 SECONDARY FOOTBALL F 18 1
2018 SECONDARY FUTSAL F 12 1
2018 SECONDARY GYMNASTICS (MAG) M 3 1
2018 SECONDARY GYMNASTICS (RG) F 3 1
2018 SECONDARY GYMNASTICS (WAG) F 3 1
2018 SECONDARY SEPAK TAKRAW M 12 1
2018 SECONDARY SEPAK TAKRAW F 5 1
2018 SECONDARY SOFTBALL F 12 1
2018 SECONDARY SWIMMING M 10 1
2018 SECONDARY SWIMMING F 10 1
2018 SECONDARY TABLE TENNIS M 4 1
2018 SECONDARY TABLE TENNIS F 4 1
2018 SECONDARY TAEKWONDO M 10 1
2018 SECONDARY TAEKWONDO F 10 1
2018 SECONDARY TENNIS M 4 1
2018 SECONDARY TENNIS F 4 1
2018 SECONDARY VOLLEYBALL M 12 1
2018 SECONDARY VOLLEYBALL F 12 1
2018 SECONDARY WRESTLING M 8 1
2018 SECONDARY WRESTLING F 8 1
2018 SECONDARY WUSHU M 6 1
2018 SECONDARY WUSHU F 4 1
2018 DEMO SPORTS AEROBIC GYMNASTICS - ELEMENTARY M/F 4 1
2018 DEMO SPORTS AEROBIC GYMNASTICS - SECONDARY M/F 4 1
2018 DEMO SPORTS DANCESPORTS - ELEMENTARY (LATIN) M 1
2019 DEMO SPORTS DANCESPORTS - ELEMENTARY (LATIN) F 1
2018 DEMO SPORTS DANCESPORTS - ELEMENTARY (STANDARD) M 1
2019 DEMO SPORTS DANCESPORTS - ELEMENTARY (STANDARD) F 1
2018 DEMO SPORTS DANCESPORTS - SECONDARY (LATIN) M 1 1
2018 DEMO SPORTS DANCESPORTS - SECONDARY (LATIN) F 1
2018 DEMO SPORTS DANCESPORTS - SECONDARY (STANDARD) M 1
2018 DEMO SPORTS DANCESPORTS - SECONDARY (STANDARD) F 1
2018 DEMO SPORTS PENCAK SILAT - SECONDARY BOYS M 5 1
2019 DEMO SPORTS PENCAK SILAT - SECONDARY GIRLS F 5
2018 PARAGAMES ATHLETICS V.I. M 3 3
2018 PARAGAMES ATHLETICS V.I. F 3
2018 PARAGAMES ATHLETICS I.D. M 10 2
2018 PARAGAMES ATHLETICS I.D. F 10 2
2018 PARAGAMES ATHLETICS/SWIMMING O.H. M 2 2
2018 PARAGAMES ATHLETICS/SWIMMING O.H. F 2
2018 PARAGAMES SMIMMING I.D. M 2 2
2018 PARAGAMES SMIMMING I.D. F 2
2018 PARAGAMES BOCCE I.D. M 2 1
2018 PARAGAMES BOCCE I.D. F 2
2018 PARAGAMES GOALBALL V.I. M 2 1
2018 PARAGAMES GOALBALL V.I. F 2
Asst.CoachChaperon Total category
4B Reference:
1 5G (Enclosure No.3 to Palarong Pambansa Memorandumn No. 5 s. 2018)
14 B REGULAR DEMO
1 15 G ELEM SEC ELEM
1 6B ATHLETES 181 292 8
1 1 7G COACHES 28 42 1
1 14 B ASST. COACHES 6 7
13 B CHAPERONS 11 19
3B 226 360 9
1 4G
19 B
4B
1 5G
4G
5B
1 1 15 G
11 B REFERENCE
1 12 G DM 026 s. 2018
5B DM 029 s. 2018
1 6G DM 049 s. 2018
7B DM 064 s. 2018
1 8G
5B
1 6G
1 14 B
1 1 15 G
5B
1 6G
6B
1 7G
17 B
1 18 G
1 6B
1 1 7G
1 14 B
13 B
1 14 G
5B
1 6B
3B
1 4G
1 12 B
3B
1 4G
19 G
1 14 G
4B
1 5G
4G
13 B
1 7G
1 1 15 G
11 B
1 12 G
5B
1 6G
11 B
1 12 G
5B
1 6G
1 14 B
1 1 15 G
9B
1 10 G
7B
1 6G
5 B/G
5 B/G
1B
1G
1B
1G
1 3B
1G
1B
1G
6B
1 6G
6B
3G
12 B
12 G
4B
2G
4B
2G
3B
2G
3B
2G
673
mn No. 5 s. 2018)
PARAGAMES
SEC
18 42
3 13
2
23 55
Ilocos NortBatanes Aurora CamarinesAklan Bohol Biliran ZamboangaBukidnon
Ilocos Sur Cagayan Bataan CamarinesAntique Cebu Leyte ZamboangaCamiguin
La Union Isabela Bulacan CatanduanCapiz Cebu City Southern LZamboangaLanao del
PangasinanNueva VizcNueva Ecij Masbate Guimaras DumagueteEastern Sa Dapitan Ci Misamis Oc
PangasinanQuirino PampangaSorsogon Iloilo Lapu-Lapu Northern Dipolog CitMisamis Or
Dagupan CiTuguegaraoTarlac Iriga City Negros OccMandaue CSamar (WeIsabela Cit Cagayan de
Laoag City Cauayan CiZambales Legaspi CitBacolod CiNegros OriCalbayog CPagadian CGingoog Ci
San Carlos Santiago CiAngeles Ci Naga City Bago City Siquijor Ormoc CityZamboangaIligan City
Urdaneta CCity of Ila Cabanatuan Sorsogon CCadiz City Toledo CityTacloban City Ozamis Cit
Candon City Olongapo CTabaco Cit Iloilo City Bayawan CiMaasin City Oroquieta
Alaminos City San Jose d Ligao City La Carlota Danao CityCatbalogan City Tangub City
Vigan City San FernanMasbate CiRoxas City Tagbilaran Borongan City Valencia City
San Fernando City Gapan City Sagay City Talisay CityBaybay City Malaybalay City
Batac City Tarlac City San Carlos Tanjay City El Salvador
Munoz Science City Silay City Bais City
Balanga City KabankalanGuihulngan City
Malolos City Passi City Carcar City
San Jose City Escalante CBogo City
Mabalacat City City of Naga, Cebu
Meycauayan City
Compostela North CotaAgusan delBasilan Abra Manila Batangas Marinduque
Davao del Sarangani Agusan delLanao del SApayao Quezon CitCavite Occidental Mindoro
Davao del South CotaButuan CitLanao del SBenguet Pasay City Laguna Oriental Mindoro
Davao OrieSultan KudSiargao MaguindanIfugao Caloocan CQuezon Palawan
Davao CityCotabato CSurigao CitSulu I Kalinga MandaluyoRizal Romblon
Digos City General SaSurigao deTawi-Tawi Mt. ProvinMarikina CBatangas CPuerto Princesa City
Panabo CitKidapawanSurigao delMarawi CitBaguio Cit Makati Cit Cavite CityCalapan City
Tagum CityKoronadal Bislig City Sulu II Tabuk City Pasig City Lipa City
Island Gar Tacurong CDinagat Isl Sharif Kabunsuan ParanaqueLucena City
Mati City Bayugan CiLamitan City Las Piñas CSan Pablo City
Tangub City Cabadbaran Lanao del Sur - IB ValenzuelaCalamba City
Valencia City Lanao del Sur - IIB Malabon CiAntipolo City
Malaybalay City Maguindanao II Taguig Tanauan City
El Salvador MuntinlupaSta. Rosa City
City of SanDasmarinas City
Navotas Tayabas City
Bacoor City
Imus City
Level ELEMENTARY SECONDARY PARAGAMES
ELEMENTARY ARNIS ARCHERY ATHLETICS V.I.
SECONDARY ATHLETICS ARNIS ATHLETICS I.D.
PARAGAMES BADMINTON ATHLETICS ATHLETICS/SWIMMING O.
DEMO SPORTS BASEBALL BADMINTON SMIMMING I.D.
BASKETBALL BASEBALL BOCCE I.D.
CHESS BASKETBALL GOALBALL V.I.
FOOTBALL BASKETBALL 3x3
GYMNASTICS (MAG) BILLIARDS
GYMNASTICS (RG) BOXING
GYMNASTICS (WAG) CHESS
SEPAK TAKRAW JR. FOOTBALL
SOFTBALL FUTSAL
SWIMMING GYMNASTICS (MAG)
TABLE TENNIS GYMNASTICS (RG)
TAEKWONDO GYMNASTICS (WAG)
TENNIS SEPAK TAKRAW
VOLLEYBALL SOFTBALL
BOXING SWIMMING
TABLE TENNIS
TAEKWONDO
TENNIS
VOLLEYBALL
WRESTLING
WUSHU
DEMO SPORTS CLASS SEX SCHOOL TYPE
AEROBIC GYMNASTICS - ELEMENTARY B MALE PUBLIC
AEROBIC GYMNASTICS - SECONDARY G FEMALE PRIVATE
DANCE SPORTS - ELEMENTARY (LATIN) B/G B/G
DANCE SPORTS - ELEMENTARY (STANDARD)
DANCE SPORTS - SECONDARY (LATIN)
DANCE SPORTS - SECONDARY (STANDARD)
PENCAK SILAT - SECONDARY BOYS
PENCAK SILAT - SECONDARY GIRLS
number category coach

4B 1
4G 1
8B 2
8G 2
5B 1
5G 1
asst coach pencak silat

note
aerobics gymnatics
if coach is male
chaperon is required with female athletes
AEROBIC GYMNASTICS - ELEMENTARY
AEROBIC GYMNASTICS - SECONDARY
DANCESPORTS - ELEMENTARY
DANCESPORTS - SECONDARY
PENCAK SILAT - SECONDARY
PENCAK SILAT - SECONDARY
designation REGION RegCode Grade Level III - CENTRAL LUZON
COACH III - CENTRAL LUZON 01 Grade 1 1 AURORA
ASST. COACH 02 Grade 2 2 BATAAN
CHAPERON 03 Grade 3 3 BULACAN
41 Grade 4 4 NUEVA ECIJA
42 Grade 5 5 PAMPANGA
05 Grade 6 6 TARLAC
06 Grade 7 (Yr I) 7 ZAMBALES
07 Grade 8 (Yr II) 8 ANGELES CITY
08 Grade 9 (Yr III) 9 CABANATUAN CITY
09 Grade 10 (Yr IV) 10 OLONGAPO CITY
10 Grade 11 (SHS) 11 SAN JOSE DEL MONTE CITY
CHAPERON 11 Grade 12 (SHS) 12 SAN FERNANDO CITY
12 GAPAN CITY
13 TARLAC CITY
14 MUNOZ SCIENCE CITY
15 BALANGA CITY
16 MALOLOS CITY
17 SAN JOSE CITY
MABALACAT CITY
MEYCAUAYAN CITY
oach pencak silat
emale athletes
ELEMENTARY
SECONDARY

RSAC REGION III - DATA ENTRY As of Decemeber 14 2018.xlsm

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PALARONG PAM

Data Entry (Athlete)

nks to ronie almia, cotabato city division, region 12

Medical Certificate (regular)

Name: Dela Vega Myla C

Sex: 0 Learner Reference Number (LRN) 0

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

Myla C Dela Vega

(Use separate sheet if necessary)

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: 12/30/1899 Date: 12/30/1899

DSAC Control Number 0 0 12/30/1899

To Whom It May Concern:

This is to certify that Myla C Dela Vega has been

Certified True and Correct :

DSAC Control Number 0 0 12/30/1899

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that Myla C Dela Vega has completed

Certified True and Correct :

DSAC Control Number 0 0 0

DSAC Control Number 0 0 12/30/1899

Signature of Father Signature of Mother

(Relationship with the Athlete)

DSAC Control Number 0 0 0

To Whom It May Concern:

age 0 sex 0 born on 12/30/1899 and have found that he/she is

Date examined: _ 12/30/1899

DSAC Control Number 0 0 0

FOR PALARONG PAMBANSA ONLY

MEDICAL CERTIFICATE ABNORMALITIES

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Upper limb: shoulder wrist, hand,

Name of Athlete Myla C Dela Vega Event : 0

FOR PALARONG PAMBANSA ONLY

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

2. Have you ever been unconscious or had a concussion? YES NO YES

5. Do you have any problem in bleeding? YES NO YES

7. Have you had any surgery? YES NO YES

8. Have you ever had to stay in a hospital? YES NO YES

9. Do you have any medical dondition? YES NO YES

Myla C Dela Vega 0

DSAC Control Number 0 0 0

FOR PALARONG PAMBANSA ONLY

ATHLETES DATA PRIVACY NOTICE AND CONSENT FORM

The Department of Education engages in the collection of personal information such as

In consideration in the foregoing, I hereby authorized the Department of Education to

I am hereby authorizing the Department of Education to collect, process,retain, and

Myla C Dela Vega

Signature of Father Signature of Mother

DSAC Control Number 0 0 0

To Whom It May Concern:

This is to certify that Mr. Ms. 0 is presently

This certification is issued upon the request of 0

to coach in the Lower Meet up to 2019 Palarong Pambansa at

DSAC Control Number 0 0 0

I, 0 , of legal age, single / married, with postal address

That all the athlete of BULACAN who will participate in the

SUBSCRIBED AND SWORN TO before me this ______day of 20in

SUBSCRIBEDAND SWORN TO before me this ______day of 20in